Nutrition

Teresa V. Hurley. MSN, RN

Factors Affecting Food Habits

• Physical — – geographic location, – food technology, – income

• Physiologic — – health,– hunger– stage of development

• Psychosocial — – culture, – religion, – tradition, – education

Psycho/Social

Developmental

Human Growth and Development

• Infants through School-Age

-rapid growth with high protein, vitamin, mineral and energy demand; infant doubles birth weight in 4-5months; triples weight at 1 year

Breast Feeding encouraged

-reduces allergy risks

What other factors?

Infants

• Formula

• Cow’s milk causes GI bleeding

• Kidney’s unable to handle

• Research: milk in 1st and the development of Type I Diabetes later in life

• Honey and corn syrup maybe be source of botulism

Introduction of Solid Food

• 4 to 6 months of age

• Introduce one at a time 4 to 7 days apart to identify allergies

Toddlers

• Picky eaters around 18 months of age

• 3 meals and 3 snacks

• Calcium and phosphorous for bone growth

Hot dogs, candy, nuts, grapes, raw veggies, popcorn frequently lead to choking deaths

School Age

• Growth slower and steadier

• Check for protein, vitamins A and C

• High fat, sugar and salt intake lead to childhood obesity compounded by sedentary lifestyle

Adolescents

• Energy needs increase to meet the increase metabolic demands of growth

• protein., calcium, iron (females) and muscle growth (males)

• Fad dieting, oral contraceptive use, fast foods, skipping meals

• Eating disorders anorexia nervosa and bulimia nervosa

Young and Middle-Age

• Energy demands less

• Fetal development affected by mother’s nutritional status and weight at time of conception; protein, calcium, iron, folic acid

• Lactation: protein, calcium, Vitamins A, C, B; avoid caffeine, alcohol and drugs

Older Adults

• Lifestyle

• Income

• Lack of teeth, dentures, thirst sensation less with resultant dehydration (confusion, weakness, hot dry skin, rapid pulse

• Nutrient dense foods: peanut butter, cheese, eggs, cream and meat-based soups

Cultural

Alternative Food Patterns

• Vegetarian– Ovolactovegetarian (no meat, fish and poultry

but will have milk and eggs)– Lactovegetarians (drink milk but no eggs)– Vegans (plant foods)

-A Zen vegan eats brown rice, grains, herb teas

-Fruitarians eat only fruits, nuts, honey and olive oil

Religious Dietary Restrictions

• Islam (no pork, caffeine, ritual slaughter of animals; Ramadan fasting sunrise to sunset for a month)

• 7th day Adventists (no pork, shellfish, alcohol, vegetarianism encouraged)

• Hinduism (no meats)

• Latter Day Saints (no alcohol, tobacco , caffeine)

Risk Factors for Poor Nutritional Status

• Developmental factors

• State of health

• Alcohol abuse

• Medications

• Megadoses of nutrient supplements

Anorexia

Anorexia

-poor appetite related to ketosis an appetite suppressant

Surgical Procedures with resultant pain

Diagnostic testing (NPO, bowel evacuations)

Promoting Appetite

• Keep environment free of odors

• Oral hygiene

• Insulin, glucosteriods, thyroid hormones affect metabolism

• Antifungals alter taste

• Psychotropics affect appetite, nausea, alter taste

Nursing Interventions

• Risk for Aspiration– Assess LOC– Decrease or absent gag or cough reflex– Surgical procedures– Neuromuscular impairments– Sensory impairments

Nursing Interventions

• Upright position• Food placed stronger side of mouth• Thickening agents• Rate of eating slower to provide for

chewing and swallowing• Use clock as guide to identify food location

for visually impaired• Use assistive devices (padded forks,

spoons etc)

Nursing Interventions

• Client to direct order and preferences of food items to eat

Therapeutic Diets

• NPO nothing by mouth

• Clear Liquid: broth, bouillon cubes, tea, carbonated beverages, clear fruit juices, popsicles

• Full Liquid: add to clear liquid diet smooth textured dairy products as custard, refined cooked cereals, pureed veggies, all fruit juices

Diets Continued

• Pureed ( continue to add to the previous) scrambled eggs, pureed meats, veggies, fruits, mashed potatoes and gravy

• Mechanical Soft (add to the previous) ground or diced meats, flaked fish, cottage cheese, cheese, rice, potaotes, pancakes, light breads, cooked vegetables and fruits, canned fruits, bananas, soups, peanut butter

Diets Continued

• Soft Low Residue: add pastas, casseroles, moist tender meats, canned cooked fruits and vegetables, desserts, cakes, cookies without nuts or coconut

• High Fiber: add fresh uncooked fruits, steamed veggies, bran, oatmeal, dried fruits

• Low Sodium: 4g (no added salt) 2gm to 500mg Na diets require selective choices

Medications

• Stimulate appetite– Periactin– Megace– Marinol’

Diets Continued

• Low Cholesterol 300mg/day in accordance with AHA guidelines for serum lipid reduction

• Diabetic: Food exchanges with balanced intake of protein, CHO and fats and vary according to energy demands as exercise, pregnancy, illness

• Regular NO restrictions

Enteral Nutrition

• Short-term nutritional support– Nasogastric

– nasointestinal route

• Long-term nutritional support– Enterostomal tube

created into • stomach (gastrostomy)

– Percutaneous endoscopic gastrostomy (PEG)

• jejunum (jejunostomy)

Enteral Nutrition (EN)

• Nutrients given via the GI tract• Formula given via NGT,PEG, PEJ• Initial tube placement verified by x-ray which is the most

accurate indicator• Traditional Method for placement

– Measure distance from tip of nose to earlobe to xiphoid process of sternum

– Water soluble lubricant– Insert through naris toward posterior nasopharynx– Flex head toward chest after passage through posterior

nasopharynx– Have client mouth breathe and swallow small sips of water– Stop advancing if client choking, coughing, cyanotic

Types of Tubes

• Naso-Gastric Salem Sump

Types of Tubes

Gastrostomy Tube Jejunostomy Tube

Tube Placement

Evidence Based Research

• X-ray verification most accurate

• X-ray method not feasible, the next best method is pH testing of gastric aspirate with readings between 0-4.

• pH of 6 or more placement in lung, intestine

• Ausculatory method should not be used but in some agencies still in use

Gastrostomy or Jejunostomy Tube

• HOB elevated 45 degrees

• Auscultate for bowel sounds

• Verify placement by testing pH of gastric aspirate

• Check gastric residual– If over 100 ml notify MD– Would you replace the gastric contents?– Would you stop the feeding?

Some Complications of Feeding

• Aspiration

• Tube displacement

• Cramping from using cold formula

• Diarrhea

• Impaired skin integrity

• Nosocomial infections

Parenteral Nutrition

• Total parenteral nutrition (TPN)

• Partial parenteral nutrition (PPN)

Total Parenteral Nutrition

  TPN- Total Parenteral Nutrition

• complete form of nutrition– protein– CHO– fat– vitamin– minerals =

Indications for TPN

• Inability to eat – Ventilator dependency – Additional surgery – Altered mental status affecting ability to eat

• Diminished nutrient intake – Anorexia – Dyspepsia from medications – Gastrointestinal problems including nausea, vomiting,

diarrhea, and distention • Increased nutrient requirements

– Hyper metabolism – Nitrogen loss caused by surgery and corticosteroid

administration – Malabsorption

TPN ACCESS DEVICES

Complications of Parenteral Nutrition

• Insertion problems

• Infection

• Metabolic alterations

• Fluid, electrolyte, and acid-base imbalances

• Phlebitis

PN Complications

• Electrolyte and Mineral imbalances: refeeding syndrome-high concentrations of glucoseleads to endogeneous insulin production which leads to-cations moving from inter to intracellular (potassium, magnesium and phosphorus) which leads to cardiac dysarrthymias, CHF. Respiratory distress, convulsions, coma, death

Complications of PN

• Rapid administration of hypertonic dextrose leads to osmotic diuresis and dehydration– DO NOT SPEED UP IF BEHIND– DO NOT STOP LEADS TO HYPOGLYCEMIA

Glucose Testing

• Diabetes is a metabolic disorder– Inadequate insulin production by pancreatic

beta cells or– Insulin resistance whereby glucose unable to

cross sell membrane• Cellular starvation• Fluid and electrolyte imbalances

Diabetes

• Hypoglycemia: pancreas secretes glucagon

• Hyperglycemia: pancreas secretes insulin– Polyuria – Polydyspia– Polyphagia– Glycosuria– Ketones

Hypoglycemia

• Rapid onset with BS 80 or below • Cool, pale, diaphoretic skin• Disorientation---coma• Shaky, dizzy, agitated• Pulse maybe tachy• B/P maybe high• Seizures common• Treat with PO or IV Glucose

Hyperglycemia

• Gradual onset with BS 200 or above• Skin warm, dry, flush• Awake, lethargic• Hungry, blurred vision• Deep, rapid respirations• Pulse, weak, rapid• B/P maybe low• Breath: fruity odor• Dehydrated• Polyuria• Polydyspia• Treatment: IV, insulin and K

Glucose Monitoring

• ac and at hs• Range 70-110 mg• Insulin Coverage

– Regular Insulin (Rapid Acting) 3-4 hr– NPH/reg (Fast Acting) 30 min---24hr– Lente, NPH (Intermediate Acting) 1-3 hr---18-

28 hr– Ultra-lente (Long Acting) 4-6 hr---36 hr